Trauma to larynx and trachea following intubation and tracheostomy

Airway complications in patients with closed-head injuries

The neurologic deficits in the closed-head injury population present special problems when managing the airway. Many of these closed-head injury patients require long-term intubation with endotracheal tube or tracheostomy to treat their central respiratory problems and control oral and pulmonary secretions. Four hundred sixty-seven closed-head injury patients were seen over a five-year period. Seventy-two of these patients required long-term endotracheal intubation, tracheostomy, or both. A prospective study by direct endoscopic examination prior to decannulation showed 23 of these 72 patients (32%) had important laryngeal or tracheal findings. The principal abnormalities observed were vocal cord paralysis, tracheal stenosis, subglottic stenosis, glottic stenosis, and tracheomalacia. This study suggests also that severely mentally impaired patients (cognitive function II and III) should retain their tracheostomy because of the high morbidity and mortality among these patients (31%) when they are decannulated. This mortality was directly related to poor pulmonary toilet, with pneumonia and sepsis being the major causes of death. This study did not show that the use of steroids or ventilators in the initial management adversely effected airway complications.

Complications of long-term nasal and oral endotracheal intubation

A case of multiple complications following long-term endotracheal intubation in an adult is presented. It is important to suspect multiple injuries in such a case and to do a complete radiological and endoscopic examination. In this way various problems will be identified and treated promptly.

Ulcerative tracheo-oesophageal fistula during treatment by tracheostomy and intermittent positive pressure ventilation

Forty-four collected cases of ulcerative tracheo-oesophageal fistula following tracheostomy and assisted ventilation are reviewed. The condition followed this form of treatment in 0·5% of cases and must be distinguished from fistulae caused by accident or surgery, and also from laryngotracheal paralysis or dysfunction. The symptomatology, diagnosis, and treatment are discussed in detail. Spontaneous cure of fistulae is rare, and operative closure should be the aim. In one patient in six, surgical closure is excluded by rapid death. When surgery is possible its timing requires critical judgement. Factors requiring assessment are the condition of the patient and of the tissues around the fistula, the necessity to continue assisted ventilation, and the ability to control nutrition, tracheal aspiration from the mouth or stomach, and pulmonary infection. The mortality of those who did not die too rapidly to receive treatment was 61% without surgery and 45·5% with surgery.

Laryngotracheal obstruction complicating tracheostomy or endotracheal intubation with assisted respiration. A critical review

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Tracheostomy

In this paper a comparison has been made between excision-type window tracheostomies and classical Björk flap and modified flap tracheostomies, based upon a review of all tracheostomies performed at Harare Hospital, Salisbury, over a 20-month period, together with bronchoscopic follow-up whenever possible.

The modified flap type of tracheostomy is constructed by means of a broad-based flap dividing two tracheal rings and having rounded corners. It produces a good stoma through which tube changing can be performed with ease and safety. Any form of permanent defect in the trachea left by merely extubating a tracheostomy will almost always produce a narrowing at the level of the stoma, which is probably most severe if a flap-type of stoma has been made. Routine replacement of a modified flap will nearly always avoid this.

A serious stricture was produced in three (3%) patients in the series. In two, this was at the level of the tube tip in patients who had been on prolonged artificial ventilation; one required resection. These strictures are probably due to movement of the tube tip during ventilator therapy, and it is suggested that some method of coupling the ventilator to the tube might be devised to avoid this.